Total Cancer Pain

Pain is one of the most common and distressing symptoms described by cancer patients. However, it is not purely
a physical experience but involves various other components of human functioning, including personality, mood,
behavior, and social relations. In an attempt to describe the all-encompassing nature of pain within a whole-
person framework, Dame Cicely Saunders coined the concept of total pain [4]. She suggested that pain has
psychological, social, emotional, and spiritual components that make up the total pain experience. Yet the
contribution of each component will be specific to each individual and his or her situation. This concept has been
well accepted in the palliative care community, although some have preferred to broaden it to the concept of total
suffering, which includes multiple symptoms but also extends beyond the physical to threats to the intactness of
the person and an impending sense of disintegration of a familiar world [2].

Physical pain may be caused by direct tumor effects, by treatment, by general debility, and by unrelated
comorbidities. Spiritual distress is often overlooked in clinical assessments and will include existential questions,
the search for meaning and purpose, and anger at fate, as well as specific faith issues in some patients. Social
pain relates to the position the patient has within society and culture, financial issues, and the impact the pain has
on the family and caregivers. Psychological pain causes and is affected by fear, anxiety, and depression.

A systematic review has identified an association between psychological distress, lack of social support, and
cancer pain [7]. Cognitive, emotional, socioenvironmental and nociceptive aspects of pain and the interactions
among these factors have been discussed by many authors [1,3,5]. Others have attempted to develop a model for
multimodal interventions [6]. This approach to pain management recognizes the role of idiosyncratic patient
thoughts and beliefs in influencing the behavioral response to pain. Past experience of pain, family influences,
and contact with health care professionals will play a role.

A biopsychosocial approach to assessment and management is needed that takes into account all these areas of
the pain experience. This approach calls for a multidisciplinary team including physicians from different disciplines
(such as palliative care, oncology, chronic pain, and orthopedics), nurses, medical social workers,
physiotherapists, pharmacists, psychologists, and chaplains. Physical aspects of pain cannot be treated in
isolation. The term opioid-irrelevant pain is sometimes used to describe components of pain that are not
amenable to analgesics, such as fear or financial distress, which need different management strategies. The
various components must be addressed and treated simultaneously, and failure to do so will mean that pain is
inadequately treated in many cases. In addition, recognition that some contributions to the pain may have roots in
long-standing problems that are not easily solved and that patients may struggle to distinguish between the
different components will allow the team to set realistic goals of treatment.

References
1. Breitbart W, Payne D. In: Holland J, editor. Psycho-oncology. New York: Oxford University Press; 1998. p. 45067.
2. Cassel EJ. The nature of suffering and the goals of medicine. N Engl J Med 1982;306:63945.
3. Padilla GV, Ferrell B, Grant MM, Rhiner M. Defining the content domain of quality of life for cancer patients with pain
Cancer Nurs 1990;13:10815.
4. Saunders CM. The management of terminal malignant disease, 1st ed. London: Edward Arnold; 1978.
5. Sela RA, Bruera E, Conner-Spady B, Cumming C, Walker C. Sensory and affective dimensions of advanced cancer pain
Psychooncology 2002;11:2334.
6. Syrjalak K Chapka M. Evidence of a biopsychosocial model of cancer-related pain. Pain 1995;61:6979.
7. Zaza C, Baine N. Cancer pain and psychosocial factors: a critical review of the literature. J Pain Symptom Manage
2002;24:52642.

2009 International Association for the Study of Pain